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6. Isolation/Quarantine

Patient isolation and population quarantine comprise two methods that
have been used intermittently through history to deal with outbreaks
of infectious disease. Unfortunately, historical data would lead us to
believe that frequently they were inappropriately or unsuccessfully utilized
(Barbera et al., 2001). Both of these techniques, in varying degrees of application,
may play a significant role in controlling communicable transmission
following a large-scale bioterrorist attack or a naturally occurring
infectious pandemic. Unfortunately, knowledge and experience in the large-scale
utilization of these techniques has fallen into disuse, with no large-scale
quarantine being implemented in recent U.S. history and large-scale patient
isolation not being practiced since the advent of antibiotic treatment
for tuberculosis. These concepts are rarely studied by the health care
community today, although the recent outbreaks of severe acute respiratory
syndrome (SARS) have rekindled some interest. Because of the potential
importance of these techniques in helping combat a large-scale bioterrorist
attack, these concepts were discussed by the RMBT Working Group in an
effort to develop characteristics and identify unresolved issues associated
with having facilities successfully serve as isolation or quarantine
units.

Definitions

Historically there has been much confusion about and misuse of the
terms "isolation" and "quarantine". Useful and
coherent definitions of these terms are offered by Barbera et al. (Barbera et al., 2001).

Isolation: Separation and confinement of individuals known or
suspected (based upon signs, symptoms or laboratory findings) to be infected
with a contagious disease to prevent them from transmitting the disease
to others.

Quarantine: Compulsory physical separation, including restriction
of movement, of populations or groups of healthy individuals who have
potentially been exposed to a contagious disease.

These definitions were used in the discussion of these topics by the
RMBT Working Group.

Identified Issues

As would be expected, there was much discussion (and little agreement)
about the overall feasibility and utility of large-scale facility-based
quarantine. There is a need for states to research current statutes providing
legal authority for the public health sector to establish and enforce
quarantine, and to establish enabling legislation or draft gubernatorial
orders when current statute authority is found wanting. There were also issues identified concerning
the physical enforcement of anything other than a voluntary quarantine,
the medical decisionmaking process to decide on a large-scale quarantine
and the lack of appreciation of the severity of some of the potential
adverse consequences versus the benefits of a large-scale quarantine.
There was also discussion that home-based quarantine may be desirable
over facility-based quarantine (as been demonstrated in dealing with
SARS), although this creates problems for some vulnerable populations
such as the homeless, the disabled, and the chronically ill.

Discussion of facility-based isolation (and treatment) also revealed
several issues. Surveys of hospitals in 4 of the Region VIII States
(Colorado, Utah, Montana, North Dakota) revealed that there is a maximum
of 828 isolation beds, total, to serve these 4 States. It was also
found that in 3 States, an average of only 28 percent of the emergency
departments had isolation rooms. It is the general conclusion that this
number of isolation beds would be inadequate in the face of a large-scale
bioterrorist attack or a wide spread pandemic and would require conversion
of entire hospitals, units of hospitals or outside facilities to support
isolation.

The willingness of any hospital to become a designated isolation facility
has become an issue. Utah, in its survey, found that 23 percent of
its hospitals would be willing to be so designated, but this number,
in reality, might be smaller, based upon the fear associated with the
agent in question. Some institutions may be willing to be an isolation
facility when dealing with plague (which is treatable and can be prophylaxed
against with antibiotics) although the number might decline if dealing
with smallpox (which has very limited treatment options). Some institutions
would be willing to be designated as an isolation facility if they were
offered ongoing monetary support to enhance infrastructure and operations.
It is clear that many hospitals fear the lasting stigma associated with
being an isolation facility for a communicable agent, even after that
agent has been controlled. There was some discussion of home-isolation
for certain agents (such as smallpox), since little definitive treatment
can occur in a hospital, although this brings forward several issues
regarding family protection and support.

There was much concern expressed about the impact of the Federal Emergency
Medical Treatment and Active Labor Act (EMTALA) during a bioterrorist
event. EMTALA requires a hospital to provide a medical screening examination
for any patient presenting to the hospital's emergency department
for care. This would be very problematic in the situations of a contagious
patient showing up at a non-isolation institution, a non-contagious patient
appearing at an isolation hospital or patients appearing at an over-crowded
hospital rather than an active alternative care site. In these situations,
EMTALA would actually be an impediment to best possible medical care.
This issue can be addressed through State-level enabling legislation
or draft gubernatorial orders. Recent rule interpretations by the Centers for Medicare and
Medicaid Services (CMS) have made this less of an issue by allowing some
flexibility during a bioterrorist event.

It was repeatedly emphasized that any large-scale quarantine or isolation
effort mandates very close cooperation between local, State, and Federal
officials during both the planning and implementation stages. There have
been some efforts in these areas, but much remains to be done.

Facility Characteristics

The following facility characteristics/capabilities were identified
to establish a facility as a quarantine unit:

Willingness of facility owner to allow structure to be used
as a quarantine facility.

The following facility characteristics/capabilities were identified to
establish a facility as an isolation unit:

Willingness of facility owner to allow structure to be used
as an isolation facility—this may include reimbursement for costs
associated with returning the facility to its previous use and a predefined
plan to accomplish this.

Ability to provide other types of support, as indicated (low
level medical care for those with chronic disease, counseling, etc.).

Ability to provide protection for care providers and their families
as decided by public health experts, based upon the agent in question
(PPE, vaccination, prophylactic antibiotics).

Ability (in terms of physical layout and personnel) to limit
access and provide appropriate entry/exit of infectious patients (based
upon agent in question) and enforce (if necessary) a lockdown procedure.

Communication capability.

Ability to deal with extensive media exposure.

Potential non-hospital sites for an isolation unit become quite limited
if the assumption is made that they will be able to support the same
level of care as a hospital. If a lower level of care is accepted, sites
could include:

Conclusion

The ability to adequately provide for quarantine and isolation facilities
presents many difficult challenges and mandates close cooperation between
public health and acute medical care sectors at local, State, regional,
and Federal levels. Financial compensation may be an issue in establishing
these facilities and would best be dealt with in advance. Advance institutional
and alternative site evaluation should be performed to determine abilities/weaknesses
for the facility to support quarantine and patient isolation issues.